Sleep difficulty is something most people deal with at some time in their life. All of us have had trouble getting to sleep or getting a good night’s rest for at least a night or two due to anxiety or other factors, but for some it is a chronic problem that needs professional attention. Sleepio, an online therapy, targets this market using a web-based version of Cognitive Behavioral Therapy (CBT). Editor Dan Buckland went through the Sleepio 6 Week therapy course for review and then interviewed Dr. Colin Espie, one of the founders of the program.
I started the Sleepio course at 1:30 am after a full day of work, so clearly I had something to fix in terms of sleep schedule. After signup the user is asked 9 sets of questions in the beginning to get a baseline idea of the amount and quality of the sleep, how it affects concentration and mood, and what the user’s goals for the program. The introduction session shows you how the program will work and helps you set goals for the end of the 6 week course. Like traditional CBT the Sleepio course has a therapy contract in the beginning, weekly appointments with a set curriculum, homework between sessions including a sleep diary, group work with others in different stages of the therapy for support, and instruction in behavior modification techniques. In this web version of CBT there is not an in-person therapist at the other end of the one-on-one appointments. It is instead a series of videos and quizzes that the person works though. However, the group work is done on an online forum, with other users who are very helpful with ideas and support. The course also does a good job of keeping the user engaged, with email reminders every morning to fill in the sleep diary and it asks you to make an appointment for the weekly session. If you don’t keep to your appointment you get an email reminding you that you missed it. In fact, the emails and reminders worked so well that I found myself keeping to the course at times because I didn’t want to disappoint anyone, even though there was no one really to disappoint.
The Sleepio course is based around the concept of “Sleep Efficiency,” meaning that it cares more that all of your time in bed is spent sleeping rather than the amount of time you spend asleep. So if at the beginning of the course it calculates that you are only sleeping for 5 hours while in bed for 8 hours it will encourage you to go to bed later and wake up earlier so that you are only spending 5 hours in bed, hopefully all of it sleeping. As the course goes on it will increase the time you should spend in bed, with the goal of lengthening the time you will be sleeping while maintaining a high sleep efficiency. I began the course with a sleep efficiency in the high 70’s (70% means you are asleep 70% of the time spent in bed) and by the end I was at almost 90%. Now, several weeks after the course ended I am still in the high 80s, but am not following the regimen as closely as I was at the end of the course.
Because it is an online service, as long as you have a regular schedule you can do your appointments whenever you want. So if you work during the times that an in-person therapist would have hours this course lets you have late afternoon or early morning therapy sessions. And if it notices that you are accessing the website during the times that you are supposed to be sleeping it sends you an encouraging email saying that it knows you were up late the night before and that you should keep working at it.
Sleepio provides peer-reviewed studies to back up their methodology and results. Pointing mostly to a placebo controlled study published in the journal Sleep in 2012 they showed that online CBT users had better outcomes in terms of improved sleep efficiency compared to a group of users who spent an equal amount of time online in a placebo course and a group of users who contiued the usual treatment for insomnia (i.e. continued primary appointments and medication for sleep disturbances). However, the online CBT performance was not compared to groups who had in-person CBT.
Professor Colin Espie has been researching sleep and insomnia for over 30 years, publishing over 200 scientific papers and 5 books on the subject. He is currently active in the European Sleep Research Society and World Sleep Federation and co-founded Sleepio to allow the widest population possible to benefit from his findings.
Medgadget: Where did you get the idea to use online CBT as a method for treating sleep disorders?
Prof Espie: Over the last few years there has been a broader move towards online approaches in CBT but mostly they are fairly disappointing in terms of both technology and engagement.
Joining up with Sleepio co-founder Peter Hames it became clear that we shared the same vision: we wanted to do something with a wow factor!
MG: How is the Sleepio experience different than an in-person version of CBT treatment for sleep disorders? What are the benefits and drawbacks as compared to in-person?
PE: We developed The Prof character to give an experience that mirrors the relationship with a real life expert. Of course the user knows he isn’t real, but nonetheless it seems natural to accept him totally as a supportive, knowledgeable figure.
I had always thought that face-to-face was the gold standard, but a huge drawback is the lack of 24-7 support that’s there for people. With Sleepio the user can visit The Prof at any time, the diary is online and right there for you to use easily on your mobile, and the online community is a huge boost to motivation to stick at things to make your sleep better.
In other words, Sleepio makes evidence-based CBT for insomnia accessible to the wider population for the first time.
MG: Who are the people who would most benefit from this course? And what should they reasonably expect to get out of the course?
PE: Anyone who is keen to improve their sleep and willing to put in a bit of effort!
Lots of people with insomnia have played around with some bits of behavioural, mental or lifestyle change. But insomnia becomes an engrained bad habit, so it takes a new routine, a new approach to thinking about sleep, to shift it. CBT does that and the Sleepio approach supports people to the hilt to get lasting benefit, in just a few weeks.
The oldest person in our clinical trial was 87, so it’s not just for young people, but people of all ages and backgrounds. The benefits – well improved sleep of course, getting to sleep and staying asleep, but importantly daytime benefits too to energy, concentration and mood for example. Our research data show that these benefits are clinically significant and durable.
MG: While there is some information in the course regarding the user’s sleep disturbances effect on a partner, not much is mentioned about the effect of the partner’s sleep pattern on the patient. Was this intentional? And how did you choose the topics to cover in the course?
PE: The guiding principle when developing the programme was that every technique taught should be evidence-based. There is a world of untested and unproven treatments available on the internet and, besides sleeping pills, there has been little else for people to turn to.
One of the benefits of Sleepio is that you are taught a wide range of techniques, each of which can be tailored to your personal situation – whether this includes a partner, or children for example. Each user is encouraged to implement the techniques as best they can, supported by the online community, which is almost certain to include other people in a similar situation.
MG: Can you comment on the beta services the course offers? (Doctor Access and Fitbit Syncing) Any plans for further integration with other devices or services?
PE: Self-tracking is very popular at the moment and we’ve received lots of requests from our users to sync with other devices or services they find helpful so we’re definitely excited at the prospect of further integration.
Doctor access is also something members of the healthcare industry have frequently expressed an interest in. We are currently in the process of developing Sleepio Clinic, an online dashboard for health professionals that allows doctors to keep track of their patients’ progress through the course.
Sleepio Clinic is yet to launch publically, but we are inviting healthcare professionals to request an account here: www.sleepio.com/clinic/requestaccount/
MG: Finally, what do you see as the future of online CBT in terms of other psychiatric or psychological disorders it might be used to treat?
PE: There are already several services offering CBT-based interventions, for example for depression. I think it would be safe to say that over the next few years we will see some fantastic services emerging for a wide range of psychological problems.
I can see the online approach dovetailing with direct service provision. Some may find online enough, others will want or need to see a professional. However the two are not mutually exclusive.
We thank Prof. Espie for his responses and Sleepio for access to the course. In the interest of patient confidentiality we did not participate in the online forums because there was no way to notify other users that we were going to write about the experience.
For more, here’s Prof. Espie describing Sleepio: